1, the sources of account funds are different: the assets in the medical insurance pooling fund account come from the medical insurance expenses paid by the company and the medical insurance expenses of urban residents; The assets of the personal account of medical insurance come from the individual contributions of employees in medical insurance for employees;
2. Different functions: the medical insurance pooling fund is used for medical treatment and reimbursement in designated hospitals, and can only be used for hospitalization reimbursement. Buying drugs in pharmacies cannot be reimbursed by pooling funds; The key assets of the personal account can be used to buy drugs in designated pharmacies and medical expenses that must be paid by individuals outside the medical insurance pooling fund, and can be paid by the customer's personal medical insurance account;
3. The reimbursement ratio is different: the reimbursement of the medical insurance pooling fund is proportional, and the reimbursement ratio of urban residents' medical insurance and employees' medical insurance is different according to the different levels of hospitals. Medical insurance for urban residents has a deductible line; The assets of personal medical insurance account can be used at will as long as they are purchased and consumed in medical insurance pharmacies and treated in outpatient clinics, and there is no limit on the application threshold.
What do you mean by pooling funds to pay?
Overall fund payment refers to the basic pension in pension and medical insurance reimbursement expenses and other items paid by social security overall fund. Part of the social security fees paid by individuals and units will enter the social security pooling account, and the social security pooling fund will be used exclusively and uniformly. No individual or unit may misappropriate it.
What is the proportion of hospitalization reimbursement for medical insurance for urban and rural residents?
The proportion of medical insurance hospitalization reimbursement for urban and rural residents is as follows:
1, students, children. In a settlement year, medical expenses below RMB 6,543,800+0,800 yuan that meet the scope of reimbursement occurred. The threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 55%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no qifubiaozhun for first-class hospitals, and the reimbursement rate is 65%;
2, the elderly over the age of 70, in a settlement year, medical expenses in line with the scope of reimbursement of 6,543,800 yuan, the threshold for tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The qifubiaozhun for secondary hospitals is 300 yuan, and the reimbursement rate is 60%; There is no qifubiaozhun for first-class hospitals, and the reimbursement rate is 65%;
They are other urban and rural residents. In a settlement year, medical expenses below RMB 6,543,800+that meet the scope of reimbursement occur, and the threshold of tertiary hospitals is 500 yuan, and the reimbursement ratio is 50%; The Qifubiaozhun for hospitalization in secondary hospitals is 300 yuan, and the reimbursement rate is 55%; There is no Qifubiaozhun in first-class hospitals, and the reimbursement rate is 60%. If urban and rural residents are hospitalized for more than two times in a settlement year, starting from the second hospitalization, the Qifubiaozhun fee will no longer be charged. Transfer or hospitalization for more than two times, make up the difference of Qifubiaozhun in accordance with the provisions of transfer or hospitalization again.
Legal basis: Article 26 of People's Republic of China (PRC) Social Insurance Law.
The basic medical insurance for employees, the new rural cooperative medical system and the basic medical insurance for urban residents shall be implemented in accordance with state regulations.
Article 27
Individuals who participate in the basic medical insurance for employees will not pay the basic medical insurance premium after retirement and enjoy the basic medical insurance benefits in accordance with the provisions of the state if they reach the statutory retirement age and the accumulated payment has reached the fixed number of years stipulated by the state; Those who have not reached the fixed number of years prescribed by the state may pay the fees to the fixed number of years prescribed by the state.
Article 28
Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.